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Prevalence of Mental Illnesses 1% of the population has schizophrenia— 130,000 people in Illinois 1 to2% of the population has bipolar affective disorder—130,000 to 260,000 people in Illinois 20% of the population will experience some mental illness

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Where are people with mental illnesses? 1,400 state psychiatric hospital beds 4,000 private psychiatric hospital beds (psychiatric units in general hospitals and free standing psychiatric hospitals 12,000 persons with mental illnesses in nursing homes (5000 in nursing homes dedicated to the treatment of persons with mental illnesses—”IMDs”) 6,000 in state prisons 2,000 in county jails (at least 1,200 in Cook County Jail) TOTAL IN INSTITUTIONS (at any one time): 25,400

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Historical Data on Hospitalization In 1950, 55,000 state psychiatric hospital beds for a population of 7 million – One bed for every 127 persons Today, 1,400 state psychiatric hospital beds for a population of 13 million – One bed for every 9,285 persons Treatment Advocacy Center study argues that we need one bed for every 2,000 persons

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Trend in Involuntary Commitments to State Hospitals in Illinois Fiscal Year 1993826 15,204 total admissions Fiscal Year 1999317 9,788 total admissions Fiscal Year 2005338 10,290 total admissions Fiscal Year 2008283 10,837 total admissions

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Causes of Deinstitutionalization Development of effective psychotropic medications Unionization of hospital employees drove up costs Creation of Medicaid program which excluded federal support for most inpatient psychiatric care (“IMD exclusion”) but paid for some community care General cost containment efforts from private insurance companies, Medicare and Medicaid refused payments for lengthy inpatient stays for any medical condition (for example, “drive-by labor and delivery”) Successful civil rights complaints about conditions of confinement in state hospitals increased costs of inpatient care due to the need for more and better-trained staff and other services Changes in treatment ideology Increased procedural protections provided in commitment hearings made such hearings more difficult and expensive U.S. Supreme Court decision in O’Connor v. Donaldson, 522 U.S. 563 (1975) raised substantive standard for involuntary commitment

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Trends in Commitment Law Prior to the 1970’s involuntary psychiatric hospitalization not considered an issue of constitutional concern U.S. Supreme Court decision in Jackson v. Indiana, 406 U.S. 715 (1972) announced that involuntary commitment to psychiatric hospital constituted “a massive deprivation of liberty” U.S. Supreme Court decision in O’Connor v. Donaldson, 422 U.S. 563 (1975) prohibited involuntary commitment of persons “capable of living safely in freedom” Court specifically held that mental illness alone cannot be the basis for commitment. In the 1970s many states adopted higher standards for involuntary commitment usually requiring that the respondent be dangerous to self or others. In the 1990’s trend begins toward lowering the commitment standard. In 2008, Illinois dramatically lowers its commitment standard. Proof of harm need not include proof that the harm occur “in the near future” or that the harm be “physical” or “serious”

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Barriers to Increasing the Amount of Involuntary Commitment Lack of beds Commitment a low priority for state’s attorneys (for whom prosecuting crimes is a higher priority) No funding (from Medicare, Medicaid, private insurance or other sources) for the time of the psychiatrist whose testimony is required by law Cost and time of transportation of patient to court

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Possible Results of Increasing the Number of Person Committed to Psychiatric Hospitals Creation of more (staffed) beds This is expensive This takes time--until accomplished, one or both of the following will occur: Reduction in duration of confinement—speed up the revolving door Overcrowding

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The Fee for Service Model (traditional insurance, Medicare and Medicaid) Payment for discrete services Payer determines – That the patient is eligible – That service is covered – That the service provider is legally qualified to provide service Payer does not determine quality of service – Payment even if provider commits malpractice – Payment even if service results in death of patient Payer does not coordinate among service providers No one is responsible for outcomes Fee for service often does not work for chronic illnesses such as schizophrenia